Tuesday, April 30, 2013

Teeth & Dental Implants: Not the Same

At the recent AAE Convention, Dr. Hessam Nowzari presented a lecture on implant outcomes.  Dr. Nowzari is a diplomate of the American Board of Periodontology and the former director of advanced periodontics at USC from 1995 to 2012.

Dr. Nowzari discussed the difference between the tooth and an implant from a unique perspective. Often left out of the discussion regarding implants is the importance of the periodontium and how loss of the the periodontium (tooth, periodontal ligament, dental papilla, supracrestal fibers, lamina dura) affects the remaining gingival esthetics, including the esthetics around the dental implant.

It is well known that anterior gingival esthetics around an implant are one of the most challenging parts of implant dentistry.  The reason this is so challenging, is that the natural periodontal tissues (see image) that give the gingiva it's phenotype (appearance) are gone.  An implant's best chance at "natural-looking" gingiva/papilla is a natural tooth next door!  Dental papilla belong to teeth. 

While implants have an important part in dentistry, an implant can never effectively reform the periodontium.  The bundle bone and the family of fibers (dentogingival, dentoperiosteal, alveologingival, periosteogingival, interpapillary, intergingival, circular, semicircular, transgingival, intercircular, transeptal fibers) that create the architecture of the dental papilla all belong to the tooth.

This debate between implants and endodontics should not exist.  Implants and root canals are not alternative treatments.  If a tooth and its surrounding periodontium is in tact, we should make every effort to preserve them, because an implant cannot restore these periodontal tissues and loss of these tissues leads to a host of other challenges.

 Dr. Nowzari hosts a periodontal & implant symposium that may be one of the few (if only) implant CE events that is not sponsored or underwritten with any commercial interest (also available for download).  It may also be the only of its type where endodontists and implant surgeons are participate together.  We would highly recommend you check it out.

Thursday, April 11, 2013

Successful Endodontics in Your General Practice

Successful endodontic treatment in the general dentist's office is based upon proper case selection.
Proper case selection will allow endodontics to be a profitable, enjoyable procedure and provide a valuable service to your patients that will build your practice.

Failure to perform proper case selection will result in:
1. Frustration
2. Loss of patient confidence
3. Loss of practice revenue
4. Additional costs incurred with retreatment or repair of iatrogenic damage

The American Association of Endodontists has prepared an assessment form to help clinicians evaluate the level of difficulty associated with endodontic treatment to help the clinician decide when to refer. (click here)

To summarize this assessment form, here's a breakdown of the type of cases that are considered minimal, moderate and high difficulty level.

1. Pt is healthy, cooperative, minimal pain and/or swelling
2. Diagnostics are clear and pulpal/peripaical diagnosis made without complication
3. Tooth is easily accessible for treatment. (anteriors/premolars w/ slight inclination or rotation)
4. Canal is open, not calcified, mature apex, no resorption
5. No previous RCT
6. Root has slight curvature
7. Periodontium is healthy

1. Pt has minimal health issues, anxious - but cooperative, moderate pain and/or swelling
2. Diagnostics requiring additional evaluation (sinuses, TMD, electric pulp testing on calcified teeth)
3. Tooth accessibility is difficult - 1st molars, moderate inclination, rotation, crown, bridge, extensive decay
4. Canal is reduced in size, pulp stones, wide apex
5. Prior RCT without complication
6. Root has moderate curvature
7. Moderate periodontal disease

1. Complex health issues, difficulty cooperating, severe pain and/or swelling
2. Diagnostics difficult - confusing complex signs & symptoms, chronic oro-facial pain
3. Tooth accessibility is difficult - 2nd & 3rd molars, severe inclination, severe rotation, crown/bridges with alignment irregularities
4. Canal is calcified (not visible), S or C-shaped, canal divides in middle or apical thirds, additional roots (3 rooted bicuspid), apex is open
5. Prior RCT with complication
6. Root has severe curvature
7.History of traumatic injury (avulsion, horizontal fracture, luxation)
Each clinician must evaluate the difficulty level and select cases that match his/her skill level and cases for which they have adequate instrumentation.  Pick cases that you can do in a timely manner, without complications.  As you become more and more comfortable, select slightly more difficult cases to challenge you, always being aware of that some cases are better managed under the microscope and with the aid of CBCT.
 The following case demonstrates the benefit of proper case selection.

Root Canal on a C-shaped, 2nd molar, through a crown with mild angulation and calcified canals makes this root canal a "HIGH DIFFICULTY" level.  The clinician performing this treatment had challenges due to these issues.  Access was difficult, interpreting the c-shaped canal was difficult and C-shaped canal all led to the mesial perforation.  The calcified canals also made it difficult to instrument/fill to the apex.  The perforation was improperly managed by sealing with gutta percha and patient was not informed of the complication.

CBCT view of the issues
Retreatment completed with MTA repair of mesial perforation.
  Prognosis: Fair

Proper case selection also helps you to build relationships with your endodontist.  When you have a good working relationship with your endodontist, you can rely on him/her to help you advance your endodontic skills and experience as well as help in difficult case management.